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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEQ <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> A N Of, d S S Page-of <br /> Facility Address: 5o � � V r ��_ 1� City:- <br /> ity In__f_spe�nate*P E FA#: PR#•got o r a3 Progrt: <br /> / �/ 2, <br /> Tank/Container Information <br /> Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> ank (2820) ❑ Containers (2821) #of Containers: - TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) —� <br /> 1 Product Type: <br /> Total Capacity: / a G a gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> LR'Tank (2820) ❑ Containers (2821) #of Containers: TA#: — <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: .�0 gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: <br /> Total Capacity: gallons <br /> (per tank or cumulative for containers by product type) Install Date: <br /> Total Capacity this Page: 6Q gallons Total Capacity for Site: 3,s—Q gallons <br /> Comments: <br /> i <br /> EHD Inspector: Reviewed �a Entered Date: <br /> By Initial: �� (S By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />